Policy Manual

For access to the form, click here.

Policy JICK-E1

Bullying Report Form 

Date the alleged bullying incident (s) is reported: ____________ 

Name of person investigating alleged incident(s): _________________________ 

Position/title of investigator: __________________________________________ 

Name of complainant/person reporting bullying (by law, reports may be anonymous):  _________________________ 

Complainant/reporter is (circle one): Student   Parent   School employee    Coach/advisor   Volunteer   Other ________ 

Name(s) of alleged target(s): ___________________________________________ 

Name(s) of alleged bully(ies): ___________________________________________ Relationship between alleged target(s)/bully(ies): ___________________________ 

Date(s), time(S) and location(s) of the alleged incident(s):______________________ 

Name(s) of potential witnesses: ___________________________________________ 

Description of incident(s), including any supporting documentation (use additional pages  if more space is needed):

I agree that the information on this form is accurate and true to the best of my knowledge and belief. 

__________________________________________ ______________ 

Signature of complainant/reporter Date 

Received by:____________________________________________ 

Position/title:____________________________________________ 

Copy to building principal: Date:_____________________ 

Copy to Superintendent: Date:_______________________ 

12/28/16

*Please excuse any formatting errors.